Firm Profiles

Terminal Condition

Designing for our final days.

In the U.S., more than 10,000 people turn 65 every day, and the senior citizen population, now over 40 million, will more than double in the next four decades. Life expectancy also continues to increase in the U.S., as it has each decade for the last century. These two trends have all sorts of implications—economic, social, political, and urban.

One thing remains unchanged, however—the cultural anathema of death. Even 40 years after psychiatrist Elisabeth Kübler-Ross’s groundbreaking book On Death and Dying, we still struggle with the inevitability of our own mortality, or a loved-one’s death, when all medical solutions have been exhausted. Design, however, can be useful in this difficult period of both certainty and uncertainty about the end.

“We are trying to move the cultural dial a little more towards accepting death by offering a public salon series,” says Dr. B.J. Miller, executive director of the Zen Hospice Project in San Francisco and a palliative care physician at the University of California, San Francisco. “The sheer volume of people who will be facing death, and the increasing number of people living with complex chronic illnesses, are tectonic forces that will bring this issue out of the margins.”

Informed by Buddhist teachings that encourage meeting the eventuality of death with equanimity and compassion, the nonprofit operates a six-bed hospice facility housed in a beautiful Victorian building, where there is nothing from the outside to distinguish it as a care facility, and where inside and on the lush grounds, terminally ill people can face death in a comforting environment. “Of course, most people want to die in their own homes, but that’s simply not possible for everyone,” Miller says. “So we’ve tried to provide a home away from home.”

The ideal home, however, is relative.

“The idea of designing the optimal environment for end-of-life moments presupposes that all humans want the same thing, and I’m not sure that humans are as similar in this respect as we believe,” says Martin Siefering, AIA, a principal at Perkins Eastman and a member of AIA’s Design for Aging Knowledge Community advisory group.

“We have also seen that, as hospice services provide a great deal of end-of-life care in patients’ homes, patients who arrive at a hospice are more medically frail and functionally compromised than in the past,” Siefering says. “This has led to questions about whether the natural or man-made amenities remain as important.”

These and other considerations are likely to be explored methodically. In fact, Miller was involved in a recent four-year grant project funded by the Fetzer Institute that facilitated collaboration within a small group of academics in varied disciplines to foster integrated approaches to higher education. As its case in point, the Life Death Rebirth project chose to explore how design principles can stimulate life-affirming approaches toward death.

One of the project’s initial reports quotes the writer and activist Ken Worpole’s Modern Hospice Design: The Architecture of Palliative Care:

A hospice is a place where ordinary people face up to extraordinary challenges and, with the help of skilled and dedicated health care professionals, triumph in the face of progressive physical deterioration and sequential losses. People live until they die and it is the job of the hospice to support and enable each patient to live their life as fully as possible. It is a place for reflection and a place to search for meaning and purpose. For many, it is perhaps the first time that they have seriously addressed the fundamental issues of life and death. The hospice building must be sympathetic to, and supportive of, our best efforts. The building must be planned to the finest detail, because we cannot afford to get it wrong.

With this message as a cue, the grant recipients, per their report, would devise courses for their respective students to collaborate, “applying knowledge from architecture, medicine, and literary and writing studies, to develop real world approaches to the challenge of improving the experience of death in the American medical system.”

One of the Fetzer project team members, Ekaterini Vlahos, chair of the Architecture Department at the University of Colorado Denver College of Architecture and Planning, involved her students in various related design projects, including the development of conceptual renovation plans for Zen House.

“The students who have chosen to work on this project are very mindful in how they design space, while making connections to a broader cultural and natural context,” Vlahos says. “It’s encouraging to see young architecture students exploring this subject, but we still have a long way to go in the U.S. in regard to designing places that can enhance quality of life in the face of death.”

In fact, an original inspiration for Vlahos and her fellow grantees was Maggie’s Cancer Caring Centres, most of which are located in the U.K., which represent some of the finest examples of the transcendent power of design. Established in 1993 by writer, theorist, and landscape designer Charles Jencks and his wife, Maggie Keswick Jencks (who died two years later from breast cancer), the centers have become a respected network of nonresidential drop-in facilities to serve anyone affected by cancer. A number of architects, including Frank Gehry, FAIA, Zaha Hadid, Hon. FAIA, and Richard Rogers, Hon. FAIA, have been involved in the designs, which offer respite—and even an uplifting atmosphere—created specifically for cancer patients and their loved ones.

“Above all,” Maggie Jencks said during the planning phase of Maggie’s Centres, “what matters is not to lose the joy of living in the fear of dying.”